Our greatest glory is not in never failing, but in rising up every time we fail. -Ralph Waldo Emerson

What Mental Toughness Is…

As concepts regarding performance psychology have developed throughout the latter half of the twentieth century, the search for what mental traits make a truly superior performer, in any profession, has been a priority. There has been an abundance of research in distinct domains, from NASA to multinational corporations, that suggests the quality of mental toughness is linked to being remarkable and simply outstanding.

Surprisingly, I have found that some people in medicine find the idea, the very concept of mental toughness “distasteful” in some way, shape, or form. I would submit that this is not, in fact, due to the true nature of the subject as I refer to it or as it is discussed in the literature. Perhaps it is the connotation and psychological schema of the idea, as it has been portrayed in popular culture and various media outlets, which some academics find so objectionable. It is important to realize, however, that the powerful underpinnings of this concept go far beyond its sometimes superficial, macho, and pugnacious presentation in movies and television.

So, what is the essence of mental toughness? How do we define it? Mental toughness has been explained in different ways by different authors. Yet, quite broadly, this attribute seems to be related to concepts of motivation, managing arousal, dealing with stress, confidence, and the ability to focus and maintain concentration.1,2,3,4 Following extensive research and building on previous interpretations of the concept, Coulter et al proposed the following comprehensive definition:

Mental toughness is the presence of some or the entire collection of experientially developed and inherent values, attributes, emotions, cognitions, and behaviors that influence the way in which an individual approaches, responds to, and appraises both negatively and positively construed pressures, challenges, and adversities to consistently achieve his or her goals.5

I find this definition, while certainly inclusive, to be somewhat unwieldy for practical application. Perhaps a more user-friendly template predates Coulter and was proposed by Clough, Earle, and Sewell in 2002. Their “4C model” outlined the primary components of mental toughness. The authors proposed that it is characterized by four primary factors:

control: a tendency to feel and act as if one is influential

commitment: a tendency to involve oneself in rather than experience alienation from an event

challenge: belief that life is changeable and to view an experience as an opportunity rather than a threat

confidence: a high sense of self-belief and faith regarding one’s ability to succeed.6,7

After dissecting the concept and breaking it into it’s component parts, it seems somewhat less contentious. After all, who wouldn’t want to develop trainees that are confident and committed to providing the very best care? Who would argue that it would be bad idea to produce physicians, nurses, and paramedics that see difficult clinical interaction as an opportunity to become better care providers?

Mental Toughness and Performance

There is evidence that suggests that mental toughness is associated with enhanced performance. Kuan and Roy found that self-confidence and the ability to control negative thoughts were associated with better performance in competition.8 In addition, more elite, higher-performing athletes seem to score higher on validated tools measuring mental toughness, such as the Sports Mental Toughness Questionarre.9 Subjectively, elite performers such as Olympic gold medalist believed that mental toughness was a vital prerequisite to high-level performance.10 Although further investigation is warranted to establish more concrete connections between mental toughness and performance in areas beyond athletics, this evidence seems to provide important clues to the presence and nature of this association.

Mental toughness is a characteristic that can be taught, cultivated, and developed in a variety of ways.11,12 Many of these techniques include teaching different psychological skills in conjunction with other training methodologies; for example, individuals can be exposed to gradually more demanding situations to practice applying psychological skills and develop the components of mental toughness. They build confidence by overcoming more and more difficult challenges. Even if individuals make mistakes in the face of very formidable training situations, they have control. One can build his or her skills and knowledge base, readdress the situation, and succeed. Also, constructive reflection techniques can be used to maximize the learning value while reviewing failures and setbacks. Finally, including cognitive-behavioral techniques such as identifying automatic thoughts and testing the accuracy of those thoughts, can be developed to promote higher levels of optimism and confidence, key components of mental toughness.13 One comprehensive way to build confidence, teach stress management techniques, and foster mental toughness is Stress Inoculation Training (full post on Stress Inoculation training).

Concepts of Mental Toughness in Medicine

The quality of equanimity, having the proper mental balance or “evenness of mind especially under stress”14, has been valued by different cultures throughout the course of human existence. This is especially true of professions that are expected, by their very nature, to intervene and mitigate emergencies or crisis situations. Resuscitation of critically ill or injured patients is one of these situations. In his address to the faculty and students of the University of Pennsylvania in 1889, titled Aequanimitas, Sir William Osler said:

In the first place, in the physician or surgeon no quality takes rank with imperturbability, and I propose for a few minutes to direct your attention to this essential bodily virtue…Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.15

Osler’s concept of “imperturbability” shares similarities with the conventional understanding of mental toughness. Osler’s reference to “calmness amid strong, coolness and presence of mind,” is very much like the important concept of control, specifically arousal control. Also, there are connections between Osler’s mention of “impassiveness” and the idea of commitment: an emergency medical provider needs to take action and get involved to save life and reduce suffering. Furthermore, the necessity of confidence and faith in one’s abilities is manifest in Osler’s warning about what happens to the physician who “is flustered and flurried”.

Despite Osler calling attention to this important quality more than a century ago, and even suggesting ways to attain it, few (if any) undergraduate or graduate medical training programs teach or discuss concepts of mental toughness and resilience to promote “imperturbability.” It is also seldom found in the curriculum of any nationally recognized certification course that teaches the technical skills of medical or trauma resuscitation.

Recently, however, there have been attempts to address the topic in literature and media. Psychologist Michael Asken, PhD published a book in 2009 titled Code Calm: Mental Toughness Skills for Medical Emergencies.16 In 2012, Whitelock and Asken completed a publication specifically targeting physicians, nurses, paramedics, firefighters and EMTs that work outside the hospital, Code Calm on the Streets: Mental Toughness Skills for Pre-Hospital Emergency Personnel.17 These innovative books adapt various psychological skills and techniques that have been used to develop mental toughness in areas such as athletics or the military, and adapt them to the world of emergency medicine.

Developing mental toughness

So, how do we develop mental toughness in the various career fields involved the care of critically ill and injured patients? We know that mental health issues such as depression and suicide are a serious problem in medicine.19,20 Could cultivating elements of mental toughness in doctors, nurses, paramedics, and other health professionals help improve mental health? Stay tuned for a future post.

In the mean time…

Let me know what you think. Do you think that resilience training for medical, paramedic, and nursing students is necessary or possible? Do you think building mental toughness for resuscitationists of all levels is needed?

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Cite this post as:

Mike Lauria. Imperturbability: William Osler, Resilience, and Redefining Mental Toughness by Mike Lauria. EMCrit Blog. Published on February 3, 2016. Accessed on December 19th 2018. Available at [http://emcrit.org/emcrit/imperturbability-william-osler-resilience-and-redefining-mental-toughness/ ].

Financial Disclosures

Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

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Comment Here

hi Mike I must say I admire your passion for this topic. so kudos there. You asked a salient question about whether mental toughness training/ study may reduce mental health problems in doctors/nurses/paramedics in training and during their careers. Let me flip the question . Could such training increase mental health problems? I think we both know that there is no clear answer here but the possiblity it may is not ruled out beyond question. Therefore we need to really think about what we want to achieve, lest we make things worse not better. Increasingly I have come to the conclusion that we are trying too hard to take concepts from other professions and industries and somehow force them to fit into the practice and ethos of medicine. I think we first need to define the current problems within medicine, what our goals are, realisitically and then try to look at ways to improve for future. Whether mental toughness is one area to improve upon is up for debate. Whether what we can learn from other professions is equally up for debate in this area. At least you are willing to raise awareness. I think instead of looking to other… Read more »

interesting. i think you are both correct… ketaminh is right in suggesting that “life experience” helps to allow us to be “cool” in the face of chaos. but there is more to it than that. we can be older, but not always wiser. and Mike suggests that one can attain certain skills/lessons via formal training to help us learn to be level minded and focused in times of turbulence. as Kipling wrote: “If you can keep your head when all about you Are losing theirs and blaming it on you, If you can trust yourself when all men doubt you, But make allowance for their doubting too; ” i think it is true that at some point in our careers, after perhaps a certain amount of time and experiences, and errors, we can walk into a room of trouble, excitement, perhaps resuscitation, perhaps some chaos, and lend a sense of calm , control, or as Mike quoted Osler: “Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm.” perhaps we all could use some additional “phlegm”. its a… Read more »

A culture of mental toughness or cognitive resilience or whatever you want to call it..I am not the only one who thinks we need to be careful in terms of mental health of future physicians. Specific training may improve things..but we dont really know. It may worsen things too.
I agree though..medical training culture needs to do better.http://www.idealmedicalcare.org/blog/

Minh, As always, thank you for your stimulating and thought provoking comments. First, I humbly submit to you and all the other physicians that I sincerely admire in terms of clinical experience as well as experience with many of these troubling mental health issues. I am, I recognize, only in the nascent stages of my career as a physician. So, feel free to object if my opinions seem naive and misconstrued. That said, coming into this training with outside perspective has, I believe, allowed me to provide a somewhat distinct view on the current state of education and training (at least in the US). I agree. Things need to change. I think they certainly can change. The issue of mental health has been an issue as long as I can remember in healthcare for everyone including physicians, nurses, and paramedics. The literature shows publications going back to 2003 and earlier discussing the problem. Yet still, here we are going to memorial services and watching colleagues and friends endure depression, substance abuse, and host of other mental health struggles. I suggest that by finding novel, dynamic ways to build commitment, generate self-efficacy, shore up confidence, and change mindset we may be… Read more »

thanks Mike. I think we can agree to disagree which is fine.
The current medical culture is one molded from decades of medical tradition stretching back to Osler who advocated a virtual monastic style of medical training, whereby junior doctors lived onsite and tended to patients. Residency as it still is was forged from this ideal. Mental toughness as Osler advocated was forged by an almost religious devotion to medicine. with daily rituals of ward rounds, study and hospital tasks.

So the culture forged then and now is the same one that leads to the mental health problems that plague our profession. I therefore do not understand how promoting more mental toughness will assist the issue before us.
The culture needs to change, not the trainees need to get tougher.

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2 years ago

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Fredrik Granholm @TotalResus

Thanks Mike for another interesting post!
Have enjoyed reading the pro/con comments as well 🙂
I think that resilience training and mental toughness training/knowledge is a must for people in high stress and high risk environments like EM, critical care, resus, hems etc. My own opinion is that a sound knowledge of the concepts before you get a taste of the real heat will both benefit your own mental health and well being, as well as your patients. Sure you will probably get wiser and “tougher” as the years go by, but having these tools will make the journy smoother and faster.
One thing to remember is that the whole team needs training in these concepts to be really effective. I am sure that your experience from elite military units is that the whole team needs the same resilience and the same “mental wavelength” to work in a safe and efficient manner. Unfortunately this concept is often lacking in (at least swedish) EM.

Thanks for an interesting post. I think however that the notion of mental toughness is dangerous in the way it makes an individual’s performance and emotional well being a entirely personal responsibility, when many of the causes of burnout and failure are structural in nature. In that way it bears resemblance with positive psychology that have been criticized for making matters worse for individuals who cannot – for one reason or another – live up to the tyranny of staying positive.
That said I agree completely with the idea that we need to train more purposely and in that way can learn from elite performers such as athletes, soldiers or musicians.

Hey Martin, Thanks so much for reading and your insightful response. I agree with your point that the causes of burnout and failure (at least as they are reported in the literature) are primarily structural in nature. Indeed, as I mentioned in my response to Minh, there are numerous cultural aspects that need to change. Keep in mind, however, that these issues are mainly related to chronic stresses, not the acute stresses to which I am largely referring (although I grant the two are not entirely independent). I think the most beneficial effects have been documented in dealing with stress during acute, crisis situations, as opposed to the long-term stresses related to things like bullying, long hours, being overworked, under appreciated, etc. That said, I disagree that the concept is dangerous. One of the issues that I see with people in training around me (and this may just be subject to my local circumstance) at both clinical and pre-clinical levels is clamoring to “change the system.” While I don’t disagree with them in theory, I fundamentally disagree with the approach of not looking in the mirror first. I think is starts with the individual trainee. Sitting around, talking about the… Read more »

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2 years ago

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Martin Schönemann-Lund

Hi Mike. Thank you for your extensive answer. I’m glad that you are open to risks of imposing the responsibility of a system failure upon the individual, and I fully agree with you that we all have to look in the mirror and try to improve ourselves before we can expect anyone or anything else to change. By training and improving our performance as teams and individuals and keeping away from “a tyranny of the toughest”, I think we can get the best out of both approaches. Looking forward to your developments of the concepts.

Best regards

Martin

PS: No, we haven’t found a way to change large health organizations to the better in any way that can be described as fast 🙂 Will let you know if it ever happens.

As a current MS3 and budding EM doc, I’d love to have something like this in undergraduate medical education. I think too often we delude ourselves into thinking the ability to study hard or stay up late is mental toughness. While yes, it does take stamina and discipline to study for the step exams or get through an overnight call, it says nothing of one’s ability to act as the “calm amidst the storm.” I, for one, applaud your efforts on this topic and would happily engage in any training that makes me better in that regard.

Thanks Justin, I appreciate the words of support. Yeah, I agree. I think it may be really great to institute something into pre-clinical training program to help students in their clinical years deal with acute stress and the challenges they face. Thanks again for reading!

I think some very interesting points were made by Mihn and Mike in regards to the need for compassion in medicine (both towards patients and one another) as well the need for mental toughness. We must do a better job of caring for our residents who have an 80% burnout rate in IM and 90% in surgery (American Psychiatric Association 2015 Annual Meeting). We also need to teach techniques to persevere through very stressful moments such as self talk and tactical breathing. We should also teach leaders that providers need to recover after extremely high stakes cases and traumatic experiences. The list goes on.

None of these ideas are at odds with each other. They all grow from the same pot – understanding how our emotions and psychology play into performance. This is the next frontier in improving patient care and I applaud Scott, Mihn, Mike, the readers and the FOAM community for leading the way.

Mike, In my professional career as a medic, I have focused myself on learning to perform better under duress as the hundreds of hours of training, years of education and the confidence instilled by the above is for nothing if one cannot control emotions and cognative distortions under duress. It is encouraging that professionals in your position see this and are putting energy into passing the knowledge to others. I myself being a field medic for some years now, have in training my medics for the Army, worked on passing on this knowledge. I am currently a civilian paramedic and working on developing an institutionalized resiliency and mental toughness program for my agency that will occur annually. The Boy Scouts taught me to be physically strong, mentally awake and morally straight and this is the basis of my own mental toughness and for the training I conduct on the topic. Physical training inately instills mental toughness as well as the health effects of stress relief (burning off all the glucose and catacholemines circulating after a busy shift), increases the body’s ability to work in the “Grey Zone” (Grossman), and prepares muscles for exercise. Mental “awakeness” encompasses training the mind using… Read more »

That’s really cool that other organization are teaching and developing similar concepts. Love the idea of the multi-dimensional approach with body, mind, and spirit. I’m hoping to continue to develop and adapt these topics.

Thanks again.

-Mike

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2 years ago

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G. Harrison

Mike, The specific working vocabulary used by Sir W. Osler is important to understanding mental toughness. I would point you to what Wyatt Earp said in much the same period. “When I say that I learned to take my time in a gunfight, I do not wish to be misunderstood, for the time to be taken was only that split fraction of a second that means the difference between deadly accuracy with a sixgun and a miss. It is hard to make this clear to a man who has never been in a gunfight. Perhaps I can best describe such time taking as going into action with the greatest speed of which a man’s muscles are capable, but mentally unflustered by an urge to hurry or the need for complicated nervous and muscular actions which trick-shooting involves. Mentally deliberate, but muscularly faster than thought, is what I mean” Folks were thinking this through in great detail even in that period. All aspects of stress management from the medical field to frontier lawmen. And the successful one understood the value. Today we are better able to codify the steps used to achieve SET, and face some backlash from the general community… Read more »

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2 years ago

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G. Harrison

I should add that successful implementation of SET caused a significant increase in successful outcomes during critical incidents.

In ALL cases so far, during debrief everyone that was a part of phased SET felt that it aided in the outcome of the incident, and all thus far felt they were better able to handle the changing environment as a result. Follow up interviews indicate that SET lowered psychological trauma to the responder in 3/6/12 month reviews, with none expressing symptoms 12 months later.

We should operate inside our skill/capability envelope. Training, repetition, and SET allow us to expand that envelope in any field where critical stress is going to be a large component.

Mike, Great article. There’s no question in my mind that this kind of training, if executed carefully and thoughtfully, would improve the effectiveness of resuscitation by critical care providers. I sense however, and as you have already alluded to in a couple of your articles, a certain resistance by the greater medical field. Perhaps you’re aware of a recent NYTimes article contemplating why doctors commit suicide (http://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html?_r=2). In this article, the idea of Osler’s “Imperturbability” is directly attacked as being in a way partly responsible for physician suicide, contributing to this hostile culture of medical education. I disagree, I think it’s more multifactorial and complicated than that, and the underpinnings of those unfortunate events have more to do with personal issues tied to the unique situations of every individual, whereas Osler’s idea of imperturbability, as you say, is widely misunderstood as some “pugnacious” and egoistic approach to medicine lacking in empathy. Bottomline, if a team of healthcare providers (paramedics, nurses, ER docs, trauma surgeons, etc) were taking care of MY family after a terrible accident, I would not only hope, I would EXPECT that team to be 100% on top of their game. Given the absence of this kind of… Read more »

I think there is a difference between the people that say “Hey, you need to toughen up and deal with it?” vs. “We need to develop resilience in our trainees and colleagues.” Ostensibly, they are similar. I would argue that is not so. Also keep in mind that I’m talking about resilience in ACUTELY stressful clinical situations, not dealing with unruly, rude, or disrespectful colleagues. Although developing resilience may help with the chronic stresses of the medical profession, I don’t necessarily have the evidence to support that quite yet.

Also, as I have pointed out in the past, I hear constant clamoring to change medical culture. While this is a noble and reasonable pursuit, we’re kidding ourselves if we think it is going to change things tomorrow. It is much easier to get up in the morning, look at your self in the mirror, and consciously decide to build resilience in yourself. That, I think, is an important point.